Nokea
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
- A. I want to protect my child from any falls.'
- B. I will set limits on exploring the house.'
- C. I understand our child's need to use those new skills.'
- D. I intend to keep control over our child's behavior.'
Correct Answer: C
Rationale: I understand our child's need to use those new skills.' Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.
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A diabetic client asks the nurse why she should use a diaphragm as a method of contraception instead of birth control pills. The best explanation for the use of a diaphragm is:
- A. A diaphragm will best prevent pregnancy because oral contraceptives are rendered ineffective by increased glucose levels.
- B. A diaphragm is a noninvasive method of contraception that will not alter the blood glucose levels.
- C. A diaphragm will provide intrauterine contraception by preventing implantation of the embryo.
- D. A diaphragm is a noninvasive method of contraception that prevents the egg from being released from the ovary.
Correct Answer: B
Rationale: A diaphragm does not affect blood glucose, unlike oral contraceptives, which can alter glycemic control. Oral contraceptives are not ineffective due to glucose levels, diaphragms do not prevent implantation or ovulation, and they are not intrauterine.
The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching?
- A. I can expect the cord to turn black in a few days
- B. I should let the cord fall off by itself
- C. I’ll give my newborn sponge baths until the cord falls off
- D. I’ll secure the diaper over the cord to protect it
Correct Answer: D
Rationale: Securing the diaper over the cord traps moisture, increasing infection risk. The cord turning black, falling off naturally, and sponge baths are correct cord care practices.
The nurse is caring for a client who has subclavian central venous access. Which nursing intervention is most important to prevent the spread of infection to this client?
- A. Frequent hand hygiene
- B. No artificial nails
- C. Use of chlorhexidine bath wipes
- D. Wearing personal protective equipment
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective intervention to prevent infection in central venous access, reducing pathogen transmission. No artificial nails and chlorhexidine wipes are supportive, but hand hygiene is primary. PPE is situational.
The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed? Select all that apply.
- A. Client determined brain dead was taken off life support
- B. Client with alcohol intoxication physically assaulted a nurse
- C. Serum troponin level was prescribed but never obtained
- D. Staff nurse did not present for work and did not notify management
- E. Visitor fell and refused care in the emergency department
Correct Answer: B,C,D
Rationale: Assault, missed lab tests, and staff no-show are reportable incidents due to safety, care quality, and staffing issues. Brain death withdrawal follows protocol, and a visitor’s fall with refused care is less reportable.
The nurse is caring for several clients who are to have diagnostic tests. Which clients will receive similar instructions?
- A. The client who is having an upper GI series and the client who is having a lower GI series
- B. The client who is having a gallbladder sonogram and the client who is having a gallbladder x-ray
- C. The client who is having a barium enema and the client who is having a colonoscopy.
- D. The client who is having a gastroscopy and the client who is having a colonoscopy.
Correct Answer: C
Rationale: A barium enema and a colonoscopy both require a clear liquid diet and full bowel prep the day before. The only difference is that the client who is having a barium enema can have red liquids and the one who is having a colonoscopy cannot. The preparation for an upper GI series is NPO after midnight the night before. There is no preparation for a gallbladder sonogram. A gallbladder x-ray requires fat restriction the day before, taking iodine dye tablets, and NPO after midnight. The preparation for a gastroscopy is NPO after midnight the night before.